Form A Actual 2024 Exam
A nurse enters a client's room and finds the client lying on the floor in a
puddle of water. Which of
the following statements should the nurse document in an incident
report?
A. Client fell out of bed because an assistive personnel left the rails of the
bed down
B. Client's roommate thinks the client is confused and fell when getting
out of bed
C. Client appears to have slipped in water but reports no injuries
D. Client found lying on the floor near the bedside table - ✔️CORRECT
ANSWER✅-Client found lying on the floor near the bedside table
A charge nurse on a pediatric unit is making assignments for a float
nurse from the medical unit.
Which of the following clients is appropriate to assign to the float nurse?
,A. A 10-year-old client who has pneumonia and is receiving respiratory
treatments
B. A 4-year-old client who has a Wilms tumor and is receiving
chemotherapy
C. An 8-month-old client who is scheduled for a surgical repair of a
ventricular septal defect tomorrow
D. A 14-year-old client who is scheduled for discharge today following
placement of a Herrington rod - ✔️CORRECT ANSWER✅-A 10-year-old
client who has pneumonia and is receiving respiratory treatments
A nurse is preparing to administer vancomycin to a client who has an
infected wound. The nurse
should plan to monitor for which of the following adverse reactions?
A. Hepatotoxicity
B. Ototoxicity
C. Hypercalcemia
D. Hypertension - ✔️CORRECT ANSWER✅-Ototoxicity
A nurse is caring for a client who is receiving total parental nutrition. For
which of the following
,findings should the nurse monitor as a potential complication of TPN?
A. Constipation
B. Respiratory depression
C. Hypotension
D. Electrolyte imbalance - ✔️CORRECT ANSWER✅-Electrolyte
imbalance
A nurse is analyzing the laboratory data on a client who has dehydration.
Which finding should
the nurse anticipate in a client who has fluid volume deficit?
A. Decreased serum osmolarity
B. Decreased hematocrit
C. Elevated blood urea nitrogen
D. Lower urine specific gravity - ✔️CORRECT ANSWER✅-Elevated
blood urea nitrogen
A nurse is performing high-frequency chest compressions using a
mechanical chest compression
, device for a child who has cystic fibrosis. Which of the following findings
indicates the treatment has
been effective?
A. The child develops a dry, hacking cough
B. The child has increased nasal secretions
C. The child has increased sputum production
D. The child develops diminished breath sounds - ✔️CORRECT
ANSWER✅-The child has increased sputum production
A nurse in an inpatient mental health facility is caring for a client who has
major depressive
disorder and refuses to take her medication. Which of the following
actions should the nurse take
first?
A. Explain to the client the consequences of refusal
B. Identify the reason for the client's refusal
C. Document the client's refusal in the medical record